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INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-10036 (01/06) 1
Form ApprovedOMB No. 0938-0842
CMS-10036.qxp 1/30/06 12:59 PM Page 1
INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-10036 (01/06) 2
CMS-10036.qxp 1/30/06 12:59 PM Page 2
INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-10036 (01/06) 3
CMS-10036.qxp 1/30/06 12:59 PM Page 3